Owner's name

Business name

Description of business

Legal entity --- Individual Partnership Corporation     Doing business as

Mailing address

City    State     Zip

Phone     Fax

eMail

BUILDING 1

Property address

City    State     Zip

Property ownership --- Own Lease Rent (if you own the property, choose Bldg. Type & Purchase date)

Building type --- Office Industrial Apartment Strip Mall     Date purchased

# of occupants     Building construction type --- Wood Frame Brick/Masonry Masonry Veneer Steel Other

Type of occupants

# of square feet occupied     Year built     # of units to insure

Building sprinkler % --- None Partial Half All     Parking type --- None Private Public Street Garage     Security system --- None Central Guard Local

Building improvements and date (if any)

BUILDING 2

Property address

City    State     Zip

Property ownership --- Own Lease Rent (if you own the property, choose Bldg. Type & Purchase date)

Building type --- Office Industrial Apartment Strip Mall     Date purchased

# of occupants     Building construction type --- Wood Frame Brick/Masonry Masonry Veneer Steel Other

Type of occupants

# of square feet occupied     Year built     # of units to insure

Building sprinkler % --- None Partial Half All     Parking type --- None Private Public Street Garage     Security system --- None Central Guard Local

Building improvements and date (if any)

BUILDING 3

Property address

City    State     Zip

Property ownership --- Own Lease Rent (if you own the property, choose Bldg. Type & Purchase date)

Building type --- Steel Wood Block     Date purchased

# of occupants     Building construction type --- Wood Frame Brick/Masonry Masonry Veneer Steel Other

Type of occupancy --- Office Individual Apartment Strip

# of square feet occupied     Year built     # of units to insure

Building sprinkler % --- None Partial Half All     Parking type --- None Private Public Street Garage     Security system --- None Central Guard Local

Building improvements and date (if any)

Building amount     Business contents amount

Loss of income amount     Deductible --- $250 $500 $1000 $2500 $5000

Miscellaneous coverages and amounts

Renewal date     Current company

Please provide a brief description of any losses in the last 5 years, with occurring dates:

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